<%@page contentType="text/html" pageEncoding="UTF-8"%>
<%@taglib uri="/struts-tags" prefix="s"%>
<html>
<head>
<title>Northern health - Patient Information System</title>
</head>
<body>
	<p style="color:#ffffff;background:grey;border-radius:2px;padding-right:25px;padding-left:5px;">Welcome to Northern Health - Patient Information System</p>
	<fieldset>
		<legend>Patient information</legend>
		<s:form action="save" name="save" method="POST"
			enctype="multipart/form-data">
			<s:textfield label="Staff designation" name="info.designationOfStaff"
				maxlength="15"></s:textfield>
			<s:label labelposition="top" value="  Patient details  "
				requiredposition="left"
				cssStyle="color:white;background-color:#ff0088;border-radius:2px;padding-left:5px;padding-right:5px">
			</s:label>

			<s:radio label="Patient declined screening"
				name="info.patientDeclinedScreening" list="#{'1':'Yes','2':'No'}"
				value="2"></s:radio>

			<s:textfield label="Date screening completed (dd/mm/yyyy)"
				name="info.screeningCompletedDate"></s:textfield>

			<s:select label="Gender" name="info.gender"
				list="#{'1':'Male','2':'Female'}" value="2"></s:select>

			<s:textfield label="Age" name="info.age" maxLength="3" size="3"></s:textfield>

			<s:label labelposition="top" value="Distress Thermometer"
				requiredposition="left"
				cssStyle="color:white;background-color:#ff0088;border-radius:2px;padding-left:5px;padding-right:5pxpadding-left:5px;padding-right:5px">
			</s:label>

			<s:textfield label="Patient Distress Score"
				name="info.patientDistressScore" maxLength="3" size="3"></s:textfield>

			<s:select label="Distress Thermometer completed by"
				name="info.distressThermometerCompletedBy"
				list="#{'Dr John':'Dr John','Dr Alex':'Dr Alex'}" value="2"></s:select>
			<s:select label="If carer" name="info.ifCarer"
				list="#{'Y':'Yes','N':'No'}" value="2"></s:select>

			<s:label labelposition="top" value="Risk factor check list"
				requiredposition="left"
				cssStyle="color:white;background-color:#ff0088;border-radius:2px;padding-left:5px;padding-right:5px">
			</s:label>
			<s:radio label="Younger than 55" name="info.youngerThan55"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>
			<s:radio label="Carer of dependents" name="info.careOfDependents"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Financial Problems" name="info.financialProblems"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Stressfull Life History"
				name="info.stressfullLifeHistory" list="#{'Y':'Yes','N':'No'}"
				value="1"></s:radio>

			<s:radio label="Lack social support" name="info.lackSocialSupport"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Previous psychic history"
				name="info.previousPsychHistory" list="#{'Y':'Yes','N':'No'}"
				value="1"></s:radio>

			<s:radio label="High Alcohol Drug Intake"
				name="info.highAlcoholDrugIntake" list="#{'Y':'Yes','N':'No'}"
				value="1"></s:radio>

			<s:radio label="Anxiety or Depression"
				name="info.anxietyOrDepression" list="#{'Y':'Yes','N':'No'}"
				value="1"></s:radio>

			<s:radio label="Female" name="info.maleOrFemale"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:label labelposition="top" value="Practical problems"
				requiredposition="left"
				cssStyle="color:white;background-color:#ff0088;border-radius:2px;padding-left:5px;padding-right:5px">
			</s:label>
			<s:radio label="Child care" name="info.childCare"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>
			<s:radio label="Housing" name="info.housing"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Insurance" name="info.insurance"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Finance" name="info.finance"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Transportation" name="info.transportation"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Work/School" name="info.workOrSchool"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Treatment decisions" name="info.treatmentDecisions"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:label labelposition="top" value="  Physical problems  "
				requiredposition="left"
				cssStyle="color:white;background-color:#ff0088;border-radius:2px;padding-left:5px;padding-right:5px">
			</s:label>


			<s:radio label="Appearance" name="info.appearance"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Bathing / Dressing" name="info.bathingOrDressing"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Breathing" name="info.breathing"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Changes in Urination" name="info.urination"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Constipation" name="info.constipation"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Diarrhoea" name="info.diarhoea"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Eating" name="info.eating"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Fatigue" name="info.fatigue"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Feeling Swollen" name="info.feelingSwollen"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Fevers" name="info.fevers"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Getting Around" name="info.gettingAround"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Indigestion" name="info.indigestion"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Memory/Concentration" name="info.memoryConcentration"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Mouth Sores" name="info.mouthSores"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:label labelposition="top" value="Family problems"
				requiredposition="left"
				cssStyle="color:white;background-color:#ff0088;border-radius:2px;padding-left:5px;padding-right:5px" />

			<s:radio label="Dealing with children" name="info.dealingWithChildren"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Dealing with partner" name="info.dealingWithPartner"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Ability to have children" name="info.abilityToHaveChildren"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Family health issues" name="info.familyHealthIssues"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>


			<s:label labelposition="top" value="Emotional problems"
				requiredposition="left"
				cssStyle="color:white;background-color:#ff0088;border-radius:2px;padding-left:5px;padding-right:5px">
			</s:label>

			<s:radio label="Depression" name="info.depression"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:radio label="Fears" name="info.fears"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:label labelposition="top" value="Actions from screening"
				requiredposition="left"
				cssStyle="color:white;background-color:grey;border-radius:2px;padding-left:5px;padding-right:5px">
			</s:label>

			<s:radio label="Cultural needs" name="info.culturalNeeds"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:textarea label="List Problems" name="info.problems" rows="6" cols="35"></s:textarea>

			<s:radio label="Interpreter used" name="info.interpreterUsed"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>

			<s:select label="Language used" name="info.language"
				list="#{'1':'English','2':'French'}" value="2"></s:select>

			<s:label labelposition="top" value="Summary Patient Cancer Journey"
				requiredposition="left"
				cssStyle="color:black;background-color:#aaffaa;border-radius:2px;padding-left:5px;padding-right:5px">
			</s:label>
			<s:select label="Cancer Tumour Stream" name="info.cancerTumourStream"
				list="#{'1':'Middle','2':'Initial'}" value="2"></s:select>
			<s:select label="Cancer Tumour Stage" name="info.cancerStage"
				list="#{'1':'Middle','2':'Initial'}" value="2"></s:select>

			<s:label labelposition="top" value="Location of screening"
				requiredposition="left"
				cssStyle="color:black;background-color:#aaffaa;border-radius:2px;padding-left:5px;padding-right:5px" />

			<s:select label="Inpatient/Outpatient" name="info.inOutPatient"
				list="#{'1':'Outpatient','2':'Inpatient'}" value="2"></s:select>
			<s:select label="If Inpatient where?" name="info.inPatientLoc"
				list="#{'1':'Theatre','2':'Ward'}" value="2"></s:select>
			<s:select label="If Outpatient where?" name="info.outPatientLoc"
				list="#{'1':'Theatre','2':'Ward'}" value="2"></s:select>

			<s:label labelposition="top" value="Carer needs"
				requiredposition="left"
				cssStyle="color:black;background-color:#aaffaa;border-radius:2px;padding-left:5px;padding-right:5px" />

			<s:radio label="Practical needs" name="info.practicalNeeds"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio> 

			<s:radio label="Family needs" name="info.familyNeeds"
				list="#{'Y':'Yes','N':'No'}" value="1" /> 

			<s:radio label="Emotional needs" name="info.emotionalNeeds"
				list="#{'Y':'Yes','N':'No'}" value="1"/>

			<s:radio label="Spiritual/Religous needs" name="info.spiritualReligousNeeds"
				list="#{'Y':'Yes','N':'No'}" value="1"/>

			<s:radio label="Physical needs" name="info.physicalNeeds"
				list="#{'Y':'Yes','N':'No'}" value="1"/>

			<s:label labelposition="top" value="GP Follow up"
				requiredposition="left"
				cssStyle="color:black;background-color:#aaffaa;border-radius:2px;padding-left:5px;padding-right:5px" />

			<s:radio label="GP follow up to be actioned" name="info.gpFollowUp"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>
				
		    <s:textfield label="List GP Follow up"
                name="info.listGPFollowUp" size="40"></s:textfield>
                
			<s:radio label="Faxed to GP" name="info.faxToGP"
				list="#{'Y':'Yes','N':'No'}" value="1"></s:radio>
            
            <s:label labelposition="top" value="External Referrals"
                requiredposition="left"
                cssStyle="color:black;background-color:#aaffaa;border-radius:2px;padding-left:5px;padding-right:5px" />
                
             <s:textfield label="Referred to"
                name="info.referredTo" size="40"></s:textfield>
            
              <s:textarea label="Contact details"
                name="info.contactDetails" rows="5" cols="40"></s:textarea>
              
              <s:label labelposition="top" value="Comments"
                requiredposition="left"
                cssStyle="color:black;background-color:#aaffaa;border-radius:2px;padding-left:5px;padding-right:5px" />
              <s:textarea label="Comments"
                name="info.comments" rows="10" cols="40"></s:textarea>    		    
				
			<s:submit label="Save"  cssStyle="color:white;background-color:grey;border-radius:2px;padding-left:5px;padding-right:5px"/>
		</s:form>
	</fieldset>
</body>
</html>
